Children s Hospital Los Angeles 2026

1. Click ‘Get Form’ to open the Consultation Request Form in the editor.
2. Begin by filling in the 'Referring Facility' section with the name of your institution. Ensure that all details are accurate.
3. Enter the 'Date' of the request, followed by the 'Ordering Physician Name'. This is crucial for identifying who is making the request.
4. Provide your signature and contact information, including phone and fax numbers, as well as your address.
5. In the 'MATERIAL SUBMITTED' section, fill in patient details such as first name, last name, age, date of birth, and sex. Ensure you include MRN and Path number.
6. Complete the 'BILLING INFORMATION' section with details of the billing contact person and their institution. Remember to provide an email for invoicing purposes.
7. Review all entered information for accuracy before submitting. Missing information could delay case review.

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